Please contact the Pollution Prevention Program at (650) 372-6200, or pollutionprevention@smcgov.org if you have any questions.

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* 1. Store Name:

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* 2. Name of Store Owner/Manager:

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* 3. Store Address:

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* 4. Store Phone Number:

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* 5. Name/Title of person filling out form:

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* 6. Contact Email Address:

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* 7. Contact Phone Number:

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* 8. Store Type: (Grocery, Retail, etc.)

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* 9. Type of bag your store sells: Paper Bag, 2.25 mil or thicker plastic bag, other type of reusable bag (describe all)

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* 10. Total dollar amount spent on purchase of allowable bags in reporting period:

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* 11. Please attach copies of bag purchase records for the period of January 1st to December 31st, 2017. Attach additional documentation if reporting for multiple stores:

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

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* 12. Total dollar amount collected from allowable bag sales during reporting period:

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* 13. Please attach copies of bag sale records for the period of January 31st to December 31st, 2017. Attach additional documentation if reporting for multiple stores:

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

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* 14. Total number of allowable bags sold during reporting period:

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* 15. Summary of any efforts by your store to promote reusable bags during the reporting period:

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* 16. My business/store does not have bag purchase or bag sale records for one or more of the following reasons:

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